Earlier Goals of Care Discussions in Hospitalized Terminally Ill Patients and the Quality of End-of-Life Care: A Retrospective Study

Background: The association between physician-directed goals of care discussions (GOCDs) and the use of aggressive interventions in terminally ill patients has not been well characterized in the literature. We examined the associations between the timing of physician-directed GOCDs in terminally ill patients and the use of aggressive interventions, probability of dying in the inpatient setting, and intensive care unit (ICU) utilization. Methods: This retrospective cohort study included patients admitted to our urban community hospital in 2015 who had a terminal diagnosis on admission and either died on an inpatient unit or were discharged to hospice. The primary independent variable was the number of days from admission to GOCD, expressed as a proportion of the patient's length of stay (LOS). We used robust variance Poisson and zero-inflated negative binomial regression, as appropriate, to estimate the associations between goals of care timing and risk of having an intervention, risk of dying in the inpatient setting, odds of ICU admission, and ICU LOS. Results: A total of 197 cases were included. After adjusting for age, language, gender, insurance, dementia, and decision maker (patient versus surrogate decision maker), later GOCD was significantly associated with greater risk of having an aggressive intervention (risk ratio [RR] = 1.04, 95% confidence interval [CI] = 1.02-1.06), greater risk of death as an inpatient (RR = 1.04, 95% CI = 1.02-1.06), and greater odds of ICU admission (odds ratio = 1.19, 95% CI = 1.02-1.39). Conclusion: Later GOCDs were associated with greater risk of aggressive interventions and death as an inpatient and greater odds of ICU admission. Goals of care discussion should be done routinely and early during the hospitalization of terminally ill patients.